Remission of alcohol disorders in primary care patients. Does diagnosis matter?

BACKGROUND: Alcohol use disorders (AUDs) are prevalent in primary care patient populations. Many primary care patients with AUDs can remit without formal treatment. An understanding of the factors that predispose patients to remission may help primary care physicians provide effective brief counseling for those with mild to moderate disorders and more effectively recommend formal treatment for others. METHODS: A total of 119 eligible and randomly selected primary care patients with alcohol abuse or dependence in remission (as defined in Diagnostic and Statistical Manual of Mental Disorders, third edition, revised) participated in a semistructured telephone interview. RESULTS: Of the subjects, 59.7% were women; 50.4% had been alcohol dependent; 66.3% made a conscious decision to modify their drinking; and 62.1%, including 54.2% of the alcohol-dependent subjects, moderated their drinking without abstaining. Family, emotional, and medical issues most often prompted reduced drinking. Nearly one third of the subjects found specific strategies and rules helpful in reducing their drinking, and many cited circumstances that helped or hindered their efforts. Only 10.9% had formal alcohol treatment. CONCLUSIONS: A significant proportion of patients with AUDs remitted without formal treatment. Abstinence may not be necessary for a subset of dependent patients. When counseling patients with active AUDs, primary care clinicians are advised to counsel patients about the psychosocial and medical reasons to control drinking, promote rule-setting about drinking, help patients avoid circumstances that trigger drinking, and support patients' attempts at moderating drinking rather than abstaining. Motivational interviewing (motivational enhancement therapy) may provide a useful framework for such counseling.

Osteoporosis risk assessment by family practice faculty and residents: a chart review.

OBJECTIVE: To assess the frequency of osteoporosis risk assessment of postmenopausal women by family practice faculty and residents. METHODS: Review of 263 charts of women over 50 from 3 residency clinics. Charts were evaluated for evidence of osteoporosis risk assessments or discussion of prevention strategies during the past 2 years. RESULTS: Overall, 35% of the charts contained documentation of some discussion of osteoporosis. Female physicians discussed osteoporosis more than their male colleagues (p < 0.05). Documentation of osteoporosis discussions decreased as women aged (p < 0.05). There was no difference in rates among clinics or between residents and faculty. CONCLUSIONS: The documentation of osteoporosis discussions with high risk women was low in this sample. Strategies to improve osteoporosis screening are necessary.

Why family physicians deliver babies.

BACKGROUND: Numerous factors have been hypothesized to explain the steady decline of family physicians providing maternity care. Rather than exploring reasons for departure, we sought to learn why many family physicians choose to deliver babies. METHODS: A previously piloted questionnaire was mailed to 1300 family physicians who had attended continuing education programs related to pregnancy. The respondents were classified as: those who had always delivered babies (group 1: "Always Did"); those who had previously not delivered babies, but had started or planned to start doing deliveries (group 2: "Started Later or Plan"); and those who had never delivered babies or had previously delivered but stopped (group 3: "Will Not Do"). The study focused on the reasons respondents in the first two groups decided to deliver babies and contrasted their views with those of the third group. RESULTS: Five hundred seventy-five valid responses were returned (421 "Always Did"; 92 "Started Later or Plan"; 62 "Will Not Do"). Response patterns were similar for all geographic regions. Reasons for delivering babies that appeared with statistically significant frequency included personal enjoyment, adequate obstetrical training in residency, desire to care for younger families, and supportive obstetricians during residency. Reasons for not delivering babies included unacceptable lifestyle, a community's saturation of maternity caregivers, fear of law-suit, and absence of need to build a practice. CONCLUSIONS: Family physicians who deliver babies appear to be primarily motivated by personal enjoyment, followed by a desire to care for younger patients and adequate training in residency. Those who do not perform deliveries primarily cite the unacceptability of a maternity caregiver's lifestyle. The expectation of the practice and a lack of community need are also important influences on the decision of family physicians to deliver babies.

Residency curriculum issues in geriatrics training.

Development of a satisfactory geriatrics curriculum in a family practice residency requires realistic planning in light of the residency's resources and integration of geriatrics training activities into a comprehensive system of monitoring residents' educational needs and accomplishments. This paper, drawing on principles of curriculum design and quality improvement, proposes that: 1) goals and objectives define the scope of training; 2) instructional flexibility is essential; 3) evaluation drives the system; 4) residents deserve individualized educational care; and 5) faculty deserve educational skill development.

Longitudinal teaching of obstetrics in family practice residency programs.

Family practice residency programs teach obstetrics using both hospital service block rotations and longitudinal management of family practice center pregnant patients. A national survey was conducted to identify characteristics and outcomes of residencies using family physicians and/or obstetricians as preceptors for the longitudinal teaching of obstetrics. Obstetricians were used as preceptors in both outpatient and delivery room settings in 18% of residencies. Family physicians were used in the outpatient setting and obstetricians in the delivery room in 27% of programs. The 37% of programs using family physician faculty as preceptors in both outpatient and delivery room settings differed from other programs in four significant ways: they were most likely to be medical school or military residency programs; they were most likely to be located in the north central and mountain states; they reported greater general satisfaction with their preceptors; and more of their graduates practiced obstetrics after residency.

Development and modification of a required family medicine clerkship.

A new required clinical clerkship in family medicine at Duke University School of Medicine is described in terms of planning, implementation, and modification in response to students' evaluations. Seventy-five percent of the eight-week course involves direct clinical experience both in academic practices and community sites, and 25 percent is spent in small group seminars and workshops. Evaluations by students have been highest for the clinical experience, the clinical competence of the faculty, the teaching effectiveness of the faculty and house staff, and the overall learning experience. The ratings have been lowest for seminars, workshops, and required written projects. Several modifications made in the clerkship over a three-year period have raised the students' ratings to near their ratings of the five traditional clerkships. The data demonstrate that family medicine can be taught effectively as a core clinical rotation and can broaden the general education of medical students.

Database management in family medicine.

A computerized database will serve a practice well if physicians and staff make their expectations and needs explicit, establish clear database specifications, and use those specifications as the basis for selecting appropriate data management software and computer hardware. Any computerized database management system introduced into a practice should be thoroughly documented, and the process of implementing the system should be planned in advance. Finally, because a practice's information-related needs, expectations, and capabilities change over time, database usage should be reviewed and refined regularly.

A resource centre for practice based research.

Academic family medicine units can provide an important service to practice-based researchers. A pilot programme was set up to test the feasibility of a practice-based Research Resource Centre in the Duke-Watts Family Medicine Program to provide support and expertise to practitioners who wish to carry out research projects in their practices. Physicians gained research experience and knowledge while actually performing the research in their own practice settings. They were able to proceed with projects at their own pace and use our resources as needed. At the same time, the interest and availability of our staff provided them with the necessary momentum to see their projects to completion.

Clinical practice plans in family practice residency programs.

This paper examines clinical practice plans (CPPs), systems for remunerating physician faculty based on their clinical productivity, in family practice residency programs. A stratified random sample of residency directors responded to a CPP survey. CPPs were found significantly more frequently in residencies (usually operated by universities) either with CPPs in their parent institutions or with high patient volume. Residencies operated by community hospitals were more likely to distribute CPP benefits to faculty based on individual clinical activity, whereas residencies operated by universities were more likely to distribute equal benefits to all faculty or to include academic as well as clinical activities in the benefit determination. While most residency directors felt that CPPs brought financial benefits to a residency and to individual faculty, many directors who did not have CPPs feared that such a plan would create conflicts between patient care and teaching. A case report tracing the evolution of a CPP in one university-administered residency is presented.

A Functional Dementia Scale.

Development of a scale to quantify the severity of functional disabilities associated with dementia is described. The Functional Dementia Scale (FDS) is designed for use by caretakers of disabled elderly. It contains 20 items in three subscales: activities of daily living, orientation, and affect. Cronbach's alpha coefficient of internal consistency for the scale was .90, and test-retest correlation was .88.

Improving hypertension control: impact of computer feedback and physician education.

Two interventions designed to help physicians manage hypertensive patients were evaluated in a controlled trial: 1) computer-generated feedback to facilitate identification of poorly controlled patients; and 2) a physician education program on clinical management strategies, emphasizing patient compliance. Four physician practice teams received either computer feedback, the education program, both, or neither. Feedback team physicians received seven monthly listings of the latest visits and blood pressures of their hypertensive patients. The self-administered learning program included written clinical stimulations and associated didactic material. Experimental and control physicians were similar in baseline knowledge, patient mix and level of training. All feedback team physicians requested appointments for listed patients, and their patients made twice as many visits as control patients during the intervention period (p less than 0.05). Education team physicians showed significant gains on a content-specific post-intervention test: mean score 84 per cent compared with 74 per cent for the control group (p less than 0.005). All patient groups showed improvement in blood pressure over the study period. However, no differences between intervention teams could be detected (p greater than 0.20). The probability of missing a 10 mm interteam difference in outcome diastolic pressure was 1 per cent (power of 0.99). Strategies for further improvement in outpatient hypertension management may need to come from outside the traditional medical model.

Hospital privileges of family physicians in North Carolina.

Ninety-eight percent of the North Carolina hospitals studied grant some or all of their family physician staff general medicine privileges, while 80 percent grant some or all family physician staff coronary unit privileges. Sixty-eight percent of the hospitals grant some or all family physicians general pediatrics privileges, while 72 percent grant newborn nursery privileges. Routine obstetrics privileges are present in 67 percent of the hospitals. Only 24 percent of the hospitals grant some or all the family physicians operative surgical privileges. There is a significant difference between urban and rural hospitals in first assistant surgery privileges. Of the 38 hospitals granting first assistant privileges, 35 are rural. Family physicians in smaller hospitals, especially those having fewer than 100 beds, are less likely to be required to seek consultations. Hospitals were asked to note what privileges a new board certified family physician staff member might expect to receive. There was little change from the current pattern. This study suggests that the opportunity for extensive hospital practice by family physicians currently exists in North Carolina.

A conceptual framework for teaching geriatrics in a family medicine residency.

There is increasing recognition of the need for educational programs in geriatric medicine, a previously neglected area of medical education. Such training is particularly important in family medicine residencies because primary care physicians have provided the bulk of health care to the elderly and probably will continue to do so. There are many advantages to using a competency-based curriculum model in developing such an educational program in geriatric medicine. The competency-based model clearly states educational objectives and identifies pertinent instructional resources and evaluation methods. A competency-based curriculum model is described which divides competencies under four major goals: understanding principles of geriatric medicine, obtaining and interpreting data, managing geriatric patients, and working as a member of a health care team. Sample objectives for each goal are described, and experience using this model in a family residency is reviewed.

Teaching residents to read the medical literature.

A seminar series was developed in a family medicine training program to provide residents with skills to interpret medical studies critically. Sessions were designed to be oriented clinically, focused on methodology, and dependent on active resident participation. Subjective evaluation by perticipants was favorable. Residents who completed the series had higher scores on a practical examination of article analysis skills than a comparison group.

Recognition of depression by family medicine residents: the impact of screening.

Psychiatric problems are often encountered in general medical settings, yet physicians frequently fail to identify such problems. Validated questionnaires assessing psychiatric symptoms have been shown to be more sensitive than physicians in detecting cases of psychiatric morbidity. This study deals with depression, the psychiatric problem most frequently seen in primary care settings. A self-administered depression questionnaire was used to alert residents to possible cases of depression. Relay of information from the questionnaire significantly increased resident recognition of depression.